Condom use with random partners by users of testing and Counseling Center in std / aids

Introduction: Among the main situations of vulnerability to HIV and other sexually transmitted diseases (STD), the lack of condom use with non-fixed partners is a major problem, which affects men and women, regardless of age or marital status. Objective: To characterize the users of the Center for Counseling and Testing STD/AIDS in Juazeiro, Bahia, Brazil, whose have non-fixed partners; and to determine the prevalence of condom use in the year 2011. Methods: We developed a descriptive study using secondary data from the health service, using the Entry Form Information System of the Center for Counseling and Testing, with a global number of 408 users. In data analysis, we evaluated the distribution of variables by means of absolute and relative frequency. Results: The majority of participants were male, aged between 21–35 years with 8 years or more of schooling and about a third of them had a stable partner. The prevalence of condom use with a non-fixed partner was low (35.29%), increasing according to the schooling years. The customary use was more common among gays and bisexuals. Of those who reported having any type of STD in the past year, about 70% reported using condoms only sometimes or never. Conclusion: The use of condoms with non-fixed partners among these users is not common, being observed unsafe sexual practices that expose them and their partners at a greater risk of contamination by DST.


INTRODUCTION
The occurrence of contamination by the human immunodeficiency virus (HIV) and by other sexually transmitted infections (STI) is associated with the practice of unprotected sex, which presents as one of the main situations of vulnerability to these conditions (1) .Still, the use of condoms to prevent STIs is reduced, especially among specific groups of the population, such as younger women or those with stable partners and people with lower schooling (2) .
The absence of condom use with non-fixed partners is related to the unequal gender relations, schooling, moral and religious factors, practice of commercial sex, sexual preference, existence of a single partner (2) , besides social condition and exclusion situations resulting from adolescence (3) , among others.An investigation conducted in Testing and Counseling Centers (TCC) with adults observed that, for both sexes, with no distinction as to marital status, 86.6% used condoms only sometimes in intercourse with non-fixed partners (4) .Sexual risk behavior was also observed among adolescents, since a little more than half of them reported having used a condom in the past three sexual relationships (5) .With regard to gender, it is observed that women are more vulnerable due to the difficulty to negotiate the use of condoms, and also due to the unequal situation in which male dominance is prevalent, especially in stable relationships (6) .
Facing the difficulties to adopt the use of condoms and the dissemination of the HIV infection, the TCCs appeared in the 1980s with the objective of improving the access of the general

Palavras
We conducted this study in order to contribute with the definition of promotion and protective strategies that can result in the reduced vulnerability to STIs.

OBJeCTIVe
To characterize the users of TCC in STD/AIDS in Juazeiro, Bahia, who have more than one partner, and to observe the prevalence of condom use in 2011.

MeTHODS
A descriptive study was performed with secondary data from health services, developed in the TCC of Juazeiro, in the state of Bahia, which is managed by the Center of STD/AIDS of the Municipal Health Secretariat.It is reference for neighboring cities, and it also includes the Specialized Health Care (SHC) in STD/HIV/AIDS.
The population was comprised of users enrolled in the TCC who filled out the Entry Form Information System of the TCC (FE-SI-TCC) in 2011 and who reported having non-fixed partners.All of the FE-SI-TCCs filled out in that year were considered to be eligible for the study.Blank, duplicated, incomplete or illegible forms were excluded, as well as those of children aged less than 10 years old.Besides the FE-SI-TCC, data from the Procedure Description Sheet, adopted by the health service, were obtained.Out of the 1,227 users registered in the TCC in 2011, 932 met the eligibility criteria.Out of these, 408 (43.78%) reported having more than one partner and were considered as participants in this study.
The studied variables were grouped into sociodemographic and behavioral ones, according to the categorization presented by the response alternatives in the FE-SI-TCC, except for "age" and "reason for not using a condom with a non-fixed partner", which were categorized by the observed frequency.In order to define the prevalence of condom use, only those who reported to always use a condom were considered.
Data were collected in the service by a trained team, in its functioning hours, with previous authorization.Data were directly typed into the software Microsoft Office Excel 2007, and analysis was conducted in the statistical package Stata, version 9.0.Data analysis assessed the distribution of variables by means of absolute and relative frequency.The study used data from the study "Epidemiological survey in the Testing and Counseling Center of the Reference Unit for DST/AIDS of Juazeiro-BA", which was approved by the Human and Animal Research Ethics Committee, at Universidade Federal do Vale do São Francisco (CEEHA/ UNIVASF), protocol n. 0006/301111 CEEHA/Univasf, according to the recommendations of resolution 196/96, from the National Health Council.

ReSULTS
The prevalence of condom use with more than one partner was of 35.29%, and one third of participants reported to never use it.
Table 1 shows that most users were male, with prevalence for the age group between 20 to 35 years old.Concerning marital status, about one third of those who claimed having more than one partner also had relationships with a stable partner.With regard to schooling, most of them had eight schooling years or more, but there were also some illiterate participants.
As to behavioral features presented in Table 2, most participants were heterosexual.With regard to the reason for not using a condom in intercourses with non-fixed partners, 34.56% informed they did not like it use it, followed by 22.06%, who claimed not to use it because they trusted the non-fixed partner.Among participants, 36.27% reported having presented with some STD contamination in the past year, and there was a high percentage of absence of register of this information (33.33%).
Table 3 presents the distribution of TCC users with non-fixed partners, according to sociodemographic characteristics, with regard to the use of condom.The distribution is similar between sexes; however, among women there is higher percentage of those who report never to use condoms.The frequent use of condoms is more frequent among adolescents and elderly people; however, except for the elderly, for all other age groups the frequent use is lower than 50%.Among married/people living together or in a stable relationship, more than 70% claimed to never use a condom with non-fixed partner or only sometimes, against 61% of those who have other types of relationship.With increasing schooling years, the use of condoms also increase in all of the relationships with non-fixed partners.
In Table 4, it is possible to observe the distribution of TCC users with non-fixed partners, according to behavioral characteristics, in relation to the use of condoms.It is observed that the frequent use of condoms is more common among homosexuals and bisexualsalmost 50% -, while only one third of heterosexuals reported the frequent use.Concerning the number of partners in the past year, using it always is not common, and one fact stands out: among those who have between 50 and 100 partners and those who have more than 100 partners, condom use is of about 38 and 34%, respectively.Among those who reported having some type of STD in the past year, about 70% reported using condoms sometimes or never.

DISCUSSION
Facing the identified results, in which only one third of users reported to always use a condom, its inconsistent use is observed, which is still a problem concerning the implementation of an efficient policy to fight STDs/AIDS (3,9,10) .The reference to never using a condom, or only sometimes, is more prevalent in several studies conducted in other TCCs in the country (3,11,12) .The statement by Kaplan et al. (13) that there was significant increase in the search for condoms after the 1980s is reaffirmed by Berquó et al. (2) , who exposes there was an increase, from 63.5% to 78.6%, in the use of condoms among people with occasional partners from 1998 to 2005.A study conducted in Santa Catarina observed that the frequency of non-use of condoms with a non-fixed partner is higher than 50% for both sexes, which shows that such use is below expectations (12) .
With regard to the variable sex, several studies demonstrated the highest prevalence of female users in search for support in reference units of STD/AIDS (11,12,14) , thus maintaining the common pattern of the search for general health care (12) .However, in this study, we observed the male predominance.But it should be considered that the population counted only on individuals who reported having non-fixed partners, which would be more common among men (15) .Among genders, the use of condom was similar, and only  one third of the participants claimed to always use it in non-fixed intercourses.This result is different from that found in the study conducted in Igarassú, Pernambuco, from 2009 to 2011, with HIV positive users of the TCC.There, a significantly higher percentage of women (71.9%) claimed never to use the preservative (10) .The most frequent age group, composed of young adults aged between 20 and 35 years old, was also the most frequent one in epidemiological surveys conducted in other TCC units in Brazil (10,11,14,16) .With regard to the use of condoms, it was observed that the frequent use was more common among adolescents and elderly people, similarly to the results observed in a study that assessed the tendencies of condom use in the urban Brazilian population between 1998 and 2005, therefore noticing a significant increase in the use of condoms especially among adolescents, since this group was the most protected one when it came to occasional partners (2) .Opposite to findings in other studies, which pointed out to little adherence to the use of condoms among the elderly (17,18) , in this study the use in this age group was more frequent than in the others.However, this may be due to the fact that the number of individuals at this age group was reduced.
Concerning the marital status of interviewees, about 70% of them were single, divorced or widowers, and this group used the condom more often, which was also observed by Berquó et al. (2) .Among married people, never using protection in non-fixed relationships was more common, which is different from other studies, which observed the more frequent use of condoms by people who referred having only occasional partners (2) .Considering that most participants in this study were male, it is possible to observe the vulnerability of the female gender, especially in stable relationships, as reported by the Ministry of Health (6) .Therefore, it is possible to say that marital status is considered to be a social condition, but not a reliable indicator to assess the sexual activity or the type and number of sexual partners (19) .
With regard to schooling, we observed that the ones with 8 to 11 schooling years attended the TCC more often.As to the use of condoms, groups with higher schooling use it more often, which indicates the reduced use proportionally to decreasing schooling, thus confirming the findings of other studies (2,12) .
As to sexual preferences, heterosexuals were prevalent in the search for care, and this tendency is confirmed in a study conducted in Santa Catarina (12) ; however, in this group, the regular use of condoms was reported only by one third of the interviewees.Studies indicate the heterosexualization of the HIV epidemic, with increasing cases among heterosexuals and especially among women in stable relationships, who are exposed to being contaminated by partners with whom they cannot negotiate the use of condoms (12,20) .Among homosexuals and bisexuals, the frequency of use was higher than 50%.
Concerning the number of sexual partners in the past year, users who had more partners used protection inconsistently, since more than 70% of them never used a condom or used it only sometimes; so, as a paradox, they were the ones who used condoms the least.A similar behavior was observed in a study conducted in the TCC of São Paulo, where an approximate percentage of individuals did not use condoms frequently (11) ; therefore, the risk of STD/AIDS dissemination increases.By considering that the intercourse with multiple partners is more common for the male gender, it leads to the situation of female vulnerability (11,12) , because even the ones who usually have intercourse with a single partner have difficulties negotiating the use of protection during sexual intercourse, especially with their single partner (6) .
With regard to reasons for the absence of condoms with a non--fixed partner, the alternative "does not like it" is the most frequent one, followed by the fact of trusting the partner.These results corroborate the ones pointed out in surveys conducted in Rio de Janeiro (11) and Minas Gerais (14) .On the other hand, the study by Andrade et al. (10) observes the inversion in this order, since trusting the partner was more prevalent (33%), followed by "not liking it" (28%).Such a behavior may be a result of several factors, such as socioeconomic status and social configuration.However, sexual practices are surrounded by subjectivity and connected to the understanding of the individual about his or her own values and relations of power to which they are submitted (21) .
In the past year, 36.27% of the participants claimed to have had some STD, which is higher than the percentage observed in a TCC of Rio de Janeiro, in 2011, where 27.9% of the participants reported having had some STD (22) .It is important to mention, however, that the number of ignored responses in this variable was expressive (33.3%), which makes it difficult to conduct a more concrete assessment of such a reality.With regard to the use of condoms, it was observed that those with some type of STD in the past year use condoms less than those who did not present with any STD in the same period, which would explain the infection, and also demonstrate the lack of sensitivity of these subjects for the adoption of protective behaviors, even after the occurrence of the infection.
The study enabled to know the sociodemographic and behavioral characteristics of users with non-fixed partners who searched for care in the TCC of Juazeiro, Bahia, in 2011, as well as the prevalence of condom use.Therefore, it was possible to observe unsafe sexual practices that expose them to higher risk of contamination by STD/AIDS.In this behavior, there are subtle differences in the several factors that are involved in the use of condom in this situation.It is important to mention the prevalent risk behavior in the several assessed aspects.The reduced use of condom in relationships with non-fixed partners, by individuals who also refer having stable partners, indicates the need of attention from health services towards this population, since they are not only exposed to being contaminated, but there is also the concomitant risk for the other partners, which shows the vulnerability of some groups, as is the case of women, who have difficulties negotiating the regular use of condoms in their sexual relationships.Another aspect that calls the attention is the low schooling of users, who are more resistant to the adoption of protective measures against STD/AIDS.The development of educational and health promotion actions addressed and adequate to this audience is necessary.
With regard to study limitations, it is important to consider that secondary data were used, whose quality may be compromised to the variety of professionals who cares for registration, lack of standardization to fill out the FE-SI-TCC, possible transcription errors, difficulties to understand the questions and the presented options of answer, both from the interviewer and the interviewee, besides the large number of uninformed or ignored data, which have an impact on the obtained results.
The continuous knowledge about the health situation is important, since it enables the development of strategies that favor the construction of knowledge, opportunities and options, besides the participation and co-responsibilization of the population when it comes to preventing and controlling sexually transmitted diseases.Some organizational measures in the TCC might contribute with the production of such knowledge, such as the implementation of the Information System, which would make it easier to establish actions of epidemiologic surveillance.

CONCLUSION
The use of condoms with non-fixed partners among these users is little frequent, and unsafe sexual practices that expose them and their partners to the higher risk of STD contamination are observed.

Table 1 -
Sociodemographic characteristics of users in the Testing and Counseling Center with non-fixed partners, Juazeiro (BA), 2011

Table 2 -
Behavioral characteristics of users in the Testing and Counseling Center with non-fixed partners, Juazeiro (BA), 2011

Table 3 -
Distribution of condom use with non-fixed partners among users in the Testing and Counseling Center according to sociodemographic characteristics, Juazeiro (BA),

Table 4 -
Distribution of condom use among users in the Testing and Counseling Center with non-fixed partners according to behavioral characteristics, Juazeiro (BA), 2011 DST -J bras Doenças Sex Transm 2013;25(2):93-98